Lauren Whetstone

Feasibility and Effectiveness of System Redesign for Diabetes Care Management in Rural Areas The Eastern North Carolina Experience

Purpose Redesigning the system of care for the management of patients with type 2 diabetes mellitus has not been well studied in rural communities with a significant minority population and limited health care resources. This study assesses the feasibility and potential for cost-effectiveness of restructuring care in rural fee-for-service practices for predominantly minority patients with diabetes mellitus. Methods This was a feasibility study of implementing case management, group visits, and electronic registry in 5 solo or small group primary care practices in rural North Carolina. The subjects were 314 patients with type 2 diabetes mellitus (mean age = 61 years; 72% African American; 54% female). An advanced practice nurse visited each practice weekly for 12 months, provided intensive diabetes case management, and facilitated a 4-session group visit educational program. An electronic diabetes registry and visit reminder systems were implemented. Results There was an improvement in the percentage of patients achieving diabetes management goals and an improvement in productivity and billable encounters. The percentage of patients with a documented self-management goal increased from 0% to 42%, a currently documented lipid panel from 55% to 76%, currently documented aspirin use from 25% to 37%, and currently documented foot examination from 12% to 54%. The average daily encounter rate improved from 20.17 to 31.55 on intervention days. Conclusions A redesigned care delivery system that uses case management with structured group visits and an electronic registry can be successfully incorporated into rural primary care practices and appears to significantly improve both care processes and practice productivity.

Inhibition, contextual segregation, and subject strategies in list method directed forgetting

This experiment tested alternative explanations of list method directed forgetting effects. Two word lists were studied by 135 subjects. Between lists, subjects were instructed to remember both lists (remember group), remember both lists as well as in which list words were studied (segregate group), or to forget the first list and remember the second (forget group). All subjects took both recall and recognition tests with test order varied between subjects. Among subjects who took the recall test first, the forget group showed a directed forgetting effect (poorer performance on List 1 than List 2) with both recall accuracy, recall typing time, and recognition reaction time measures. Contextual segregation of List 1 words by forget subjects was ruled out as a sufficient cause of the effect. Limited support was obtained for a differential rehearsal explanation of the effect. Within-group comparisons and findings of release from directed forgetting support inhibitory processes as the major cause of the directed forgetting effect.

Attendance at religious services and subsequent mental health in midlife women.

Objective: Spiritual and religious factors may influence mental health in midlife women. The purpose of this study was to explore whether strength of religious beliefs or attendance at religious services helps to mitigate the stresses of life in mid-life women. Methods: Data are from a sub-sample of 265 women, ages 40–70, who were participants in the REACH study, a longitudinal study investigating health parameters in a representative sample of households from rural communities in eastern North Carolina. Using t-tests and linear regression analyses, we analyzed the relationship between frequency of attendance at religious services and strength of religious beliefs in 1997 and subsequent mental health in 2003 as measured by the mental health component score (MCS) of the SF-12. Results: The mean MCS in 2003 was significantly higher (better mental health) in women who reported attending religious services ≥1/week compared to those who reported attending <1/week (53.9 vs. 51.7; p < 0.05). In the linear regression model controlling for self-reported health status, baseline attendance at organized religious services remained a significant predictor of the MCS at six-year follow-up (standardized β = −0.123, p < 0.05). Conclusions: Attendance at religious services is positively related to subsequent mental health in middle-aged women. The findings support the notion that religious commitment may help mitigate the stress of the midlife period. More research is needed to translate these findings into clinical interventions that can decrease the burden of anxiety and depression on midlife women.

Validity Evidence for the Salutogenic Wellness Promotion Scale (SWPS)

OBJECTIVES To test the validity, reliability, and uses of the multidimensional Salutogenic Wellness Promotion Scale (SWPS). METHODS Self-reported (n = 2140) demographic and scale data from a large university (23,000+ students) were collected and analyzed. Dependent measures included grade point average (GPA) and perceived health. RESULTS Analyses confirmed the SWPSs 7-factor multidimensional structure and its use for describing and predicting associated outcomes. The analyses of frequency distributions, means, correlations, and regressions found significant relationships between measured health behaviors, perceived health, and GPA. CONCLUSIONS The SWPS provides valid and reliable information about positive health potential for research and field health professionals.

Predictive Value of Exercise Stress Testing in a Family Medicine Population

Purpose: Exercise stress testing (EST) is a screening test for coronary artery disease. Previous studies from the cardiology literature show an overall sensitivity of 67% and specificity of 72% with variable predictive values depending on pretest probability. The purpose of the current study was to evaluate the predictive value of EST in a family medicine population in eastern North Carolina. Methods: This is a retrospective case series of 339 ESTs performed in a family medicine center from July 2001 to April 2005. EST results were classified as positive, negative, or equivocal. Outcomes studied from a review of outpatient and inpatient electronic medical record data and telephone follow-up included myocardial infarction, cardiac catheterization with angioplasty and stenting, coronary artery bypass grafting, a new diagnosis of coronary artery disease, and cardiac death. Mean duration of follow-up was 47 months, with a range of 27 to 72 months. Results: Nearly all patients had low to intermediate risk pretest probability. Five tests were positive, 32 were equivocal, and 302 were negative. There were 2 false-positive tests, both in female patients. There were 2 false-negative tests, both of which were treated with good outcomes. Two of 32 equivocal results had cardiac outcomes. Considering equivocal tests as positive, the overall sensitivity in this series was 71.4%; specificity was 90.4%. The positive predictive value was 13.5% and the negative predictive value was 99.3%. Conclusions: The high negative predictive value for EST in this outpatient family medicine population is noteworthy and reassuring. EST is a cost-effective strategy for triaging the common complaint of chest pain in low- to intermediate-risk patients in primary care practices and should be included in the services offered to family medicine patients.

Implementation of the NHLBI integrated guidelines for cardiovascular health and risk reduction in children and adolescents: rationale and study design for young hearts, strong starts, a cluster-randomized trial targeting body mass index, blood pressure, and tobacco.

BACKGROUND Cardiovascular disease (CVD) and the underlying atherosclerosis begin in childhood, and their presence and intensity are related to known cardiovascular disease risk factors. Attention to risk factor control in childhood has the potential to reduce subsequent risk of CVD. OBJECTIVE The Young Hearts Strong Starts Study was designed to test strategies facilitating adoption of the National, Heart, Lung and Blood Institute supported Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. This study compares guideline-based quality measures for body mass index, blood pressure, and tobacco using two strategies: a multifaceted, practice-directed intervention versus standard dissemination. STUDY DESIGN Two primary care research networks recruited practices and provided support for the intervention and outcome evaluations. Individual practices were randomly assigned to the intervention or control groups using a cluster randomized design based on network affiliation, number of clinicians per practice, urban versus nonurban location, and practice type. The units of observation are individual children because measure adherence is abstracted from individual patients medical records. The units of randomization are physician practices. This results in a multilevel design in which patients are nested within practices. The intervention practices received toolkits and supported guideline implementation including academic detailing, an ongoing e-learning group. This project is aligned with the American Board of Pediatrics Maintenance of Certification requirements including monthly physician self-abstraction, webinars, and other elements of the trial. SIGNIFICANCE This trial will provide an opportunity to demonstrate tools and strategies to enhance CV prevention in children by guideline-based interventions.

Delivering a Behavior-Change Weight Management Program to Teachers and State Employees in North Carolina

Purpose. To ascertain the effectiveness of a behavior-change weight management program offered to teachers and state employees in North Carolina (NC). Design. Fifteen-week weight management program with premeasures and postmeasures. Setting. State agencies and public K-12 schools in five NC counties. Subjects. A total of 2574 NC state employees enrolled in 141 classes. Intervention. Eat Smart, Move More, Weigh Less (ESMMWL) is a 15-week weight management program delivered by trained instructors. Lessons inform, empower, and motivate participants to live mindfully as they make choices about eating and physical activity. Measures. Height, weight, body mass index (BMI), waist circumference, blood pressure, confidence in ability to eat healthy and be physically active, changes in eating, and physical activity behaviors. Analysis. Descriptive statistics, t-tests, χ2 tests, and analyses of variance. Results. Data are reported for 1341 participants in ESMMWL who completed the program, submitted an evaluation, and had not participated in the program in the past; 89% were female and mean age was 48.8 years. Average BMI and waist circumference decreased significantly. Confidence in eating healthfully and being physically active increased significantly. The percentage of participants with a BMI < 30 kg/m2 increased from 40% to 45% and those with a normal blood pressure increased from 23% to 32.5%. Participants reported being more mindful of what and how much they ate (92%), being more mindful of how much daily physical activity they got (88%), and eating fewer calories (87.3%). Conclusion. This project demonstrated the feasibility of implementing a behavior change–based weight management program at the worksite to achieve positive outcomes related to weight, blood pressure, healthy eating, and physical activity behaviors. Programs such as this have the potential to provide health care cost savings.

Evaluation of the Reliability and Validity of an Adult Version of the Salutogenic Wellness Promotion Scale (SWPS)

Abstract Background: Traditional health measurement tools use a pathogenic, or disease origins framework, to assess for the absence of disease or risk factors. Good or positive health, however, is more than the absence of disease and current tools do not reflect this. Purpose: The purpose of this study was to test the psychometric properties of the adult version of the multidimensional Salutogenic Wellness Promotion Scale (SWPS), a tool designed to measure positive health. Methods: Building on the previously validated young adult version of the SWPS, new scale items were developed for working adults. A sample of 304 administrative, academics, and staff personnel tested the psychometric properties of the adult version of the SWPS. Results: The SWPS demonstrated it had a seven factor multidimensional structure, had good internal consistency, and was positively correlated with perceived health (p<.0001) and life satisfaction (p<.001). Validity was also supported by negative correlations between the SWPS and both a depression and symptom measure. Discussion: The SWPS demonstrated good evidence of reliability and validity and fills a positive health status assessment need. Translation to Health EducationPractice: Using the SWPS with adult populations could assist health educators in their development of effective health promotion practices.

Adoption of Cardiovascular Risk Reduction Guidelines: A Cluster-Randomized Trial

BACKGROUND AND OBJECTIVES: Cardiovascular disease (CVD) and underlying atherosclerosis begin in childhood and are related to CVD risk factors. This study evaluates tools and strategies to enhance adoption of new CVD risk reduction guidelines for children. METHODS: Thirty-two practices, recruited and supported by 2 primary care research networks, were cluster randomized to a multifaceted controlled intervention. Practices were compared with guideline-based individual and composite measures for BMI, blood pressure (BP), and tobacco. Composite measures were constructed by summing the numerators and denominators of individual measures. Preintervention and postintervention measures were assessed by medical record review of children ages 3 to 11 years. Changes in measures (pre–post and intervention versus control) were compared. RESULTS: The intervention group BP composite improved by 29.5%, increasing from 49.7% to 79.2%, compared with the control group (49.5% to 49.6%; P < .001). Intervention group BP interpretation improved by 61.1% (from 0.2% to 61.3%), compared with the control group (0.4% to 0.6%; P < .001). The assessment of tobacco exposure or use for 5- to 11-year-olds in the intervention group improved by 30.3% (from 3.4% to 49.1%) versus the control group (0.6% to 21.4%) (P = .042). No significant change was seen in the BMI or tobacco composites measures. The overall composite of 9 measures improved by 13.4% (from 48.2% to 69.8%) for the intervention group versus the control group (47.4% to 55.2%) (P = .01). CONCLUSIONS: Significant improvement was demonstrated in the overall composite measure, the composite measure of BP, and tobacco assessment and advice for children aged 5 to 11 years.

Using Synchronous Distance-Education Technology to Deliver a Weight Management Intervention

OBJECTIVE To compare the effectiveness of online delivery of a weight management program using synchronous (real-time), distance-education technology to in-person delivery. METHODS Synchronous, distance-education technology was used to conduct weekly sessions for participants with a live instructor. Program effectiveness was indicated by changes in weight, body mass index (BMI), waist circumference, and confidence in ability to eat healthy and be physically active. RESULTS Online class participants (n = 398) had significantly greater reductions in BMI, weight, and waist circumference than in-person class participants (n = 1,313). Physical activity confidence increased more for in-person than online class participants. There was no difference for healthy eating confidence. CONCLUSIONS AND IMPLICATIONS This project demonstrates the feasibility of using synchronous distance-education technology to deliver a weight management program. Synchronous online delivery could be employed with no loss to improvements in BMI, weight, and waist circumference.